Hepatitis C in London

Annual Health Protection Agency Review (2009 data)

Health Protection Agency London

May 2011

Summary
Hepatitis C remains a major public health problem with an estimated 185,000 individuals with chronic infection in the UK1. The
Hepatitis C Action Plan for England, published in 2004, specified areas for action which included surveillance and research,
increasing awareness and reducing undiagnosed infections, high-quality health and social care services and prevention2.
This report focuses on the epidemiology of hepatitis C in London, using in the main, routinely available surveillance data .

Summary
Hepatitis C is a blood borne virus. Infection is usually asymptomatic in the early years. The majority of infected individuals are
unable to clear hepatitis C naturally and without successful treatment chronic infection can span several decades and can be
life-long. Persistent infection can lead to chronic liver disease, and in some cases hepatocellular carcinoma.
An estimated 51,000 people in London are infected with hepatitis C, the majority of whom remain undiagnosed. The number of
laboratory reports of confirmed hepatitis C diagnoses has decreased in London in recent years, with 861 diagnosed in 2009
compared to nearly 1,200 diagnosed in 2006. This may reflect changes in laboratory reporting. The incidence of hepatitis C
appears to be declining, as evidenced by a reduction in infections in younger adults.
Males are more often diagnosed as having hepatitis C than females, with the peak age group being those aged 35 to 44 years
old.
Injecting drug use remains the major risk factor, accounting for two-thirds of hepatitis C cases in London. It is estimated that
three in every five injecting drug users have hepatitis C. In the last ten years sex between men has emerged as an important
route of transmission and has been identified as a risk factor in one in 12 hepatitis C cases. Individuals originating from South
Asia, where the prevalence of hepatitis C is high, are also particularly at risk. In London, one in 33 South Asians tested positive
for hepatitis C in 2009.
If left untackled, hepatitis C infection will result in great costs, both in terms of morbidity and mortality due to chronic disease,
but also in financial costs due to treatment of the late complications of the infection. The estimated cost of treating those
already identified in London is 54 million.
Raising awareness leading to increased testing is important to identify previously unrecognised cases. Unfortunately fewer
tests were conducted in 2009 than in 2005, although there was a slight increase from 2008 to 2009. Since 2005, testing has
increased in primary care, however, testing in drug services has remained static and testing in GUM has decreased.
Prevention is primarily focused on injecting drug users (IDUs) and encouragingly there has been marked success in changing
the reported behaviour of IDUs in terms of sharing of drug paraphernalia.
Treatment can be effective at clearing the virus. It is estimated that over 1,478 people received treatment for hepatitis C in
2009 in London. Accurate figures are not available however as treatment information was only provided by a third of clinics.
It is vital that those testing positive are referred appropriately. However, only half of PCTs in London were reported as having a
treatment care pathway for people with hepatitis C and the provision for prisoners is not clear.

Recommendations
Clear and robust commissioning arrangements for hepatitis C need to be maintained during the current NHS reorganisation.
All primary care organisations should ensure that integrated and robust pathways of care are available for patients with
hepatitis C, ideally coordinated through a clinical network.

Providers of prison health services should develop testing strategies and care pathways that allow equitable access to
treatment services for offenders.

All commissioners of hepatitis C services should review the coverage of hepatitis C testing services in their area and take
measures to increase testing.

Commissioners and providers of services for injecting drug users should ensure that a broad range of prevention services (in
addition to needle and syringe exchange) is available and that a high rate of testing in those attending specialist services for
drug users is maintained. Lead agencies should ensure widespread access to testing for hepatitis C using alternative
specimens (for example, oral fluid and dried blood spot).

Commissioners should ensure that acute trusts provide robust information on the numbers of patients with hepatitis C who
are referred, seen and treated for hepatitis C and their clinical outcomes.

1. Epidemiology and burden of hepatitis C

The Health Protection Agency (HPA) report Hepatitis C in
England. The Health Protection Annual Report. 2009 provides
a comprehensive review of the epidemiology of hepatitis C in
England and Wales (available at www.hpa.org.uk)1.

Figure 1: Laboratory confirmed diagnoses of hepatitis

C from laboratories in London (2000 to 2009)3
1400

Hepatitis C is a blood borne virus. Infection is often initially

asymptomatic. The majority of infected individuals cannot
clear hepatitis C naturally and without successful treatment
chronic infection can span several decades and can be lifelong. Persistent infection can lead to chronic liver disease,
and in some cases hepatocellular carcinoma.

1200

Number

1000
800
600
400
200

Information from various sources can be used to build up a

picture of hepatitis C epidemiology in the London. However,
unfortunately we do not have complete information about
hepatitis C across the region as there is no prevalence survey
of the local general population.

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Laboratories in London do report confirmed hepatitis C diagnoses to the HPA. However, as hepatitis C is usually
asymptomatic and there is no laboratory marker of recent infection, laboratory reports often reflect patterns of testing, rather
than trends in incidence or prevalence3. In addition, laboratories have only been mandated to report since October 2010 and
therefore prior to this reporting is inconsistent and incomplete. These factors mean it is often difficult to accurately interpret
trends in laboratory reports. However, Figure 1 highlights that the number of laboratory reports of confirmed hepatitis C
diagnoses from laboratories in London has decreased from a peak of nearly 1,200 in 2006 to 861 in 2009.
Nine laboratories in London participate in the Sentinel Surveillance of Hepatitis Testing Study which means that they collect
more detailed information about testing (further information on page 10)4. Information from this study indicates that adult males
aged between 25 to 64 years old have more than double the number of diagnoses than females of the same age (Figure 2).
The highest numbers of diagnoses were in males aged 35 to 44 years old followed by males aged 45 to 54 years old and then
in males aged 25 to 34 years old.
The principle risk factor for hepatitis C is injecting drug use. Data on risk exposures are available for around 350 individuals
testing positive between 2002 and 2006 and show that injecting drug use was the main exposure in London accounting for two
-thirds of hepatitis C cases (Table 1). Over the last ten years sex between men has emerged as an important route of
transmission and was a risk factor in one in 12 cases4 (see Box 1 for more information5).
The prevalence of hepatitis C among injecting drug users is known to be high. The HPAs Unlinked Anonymised Prevalence
Monitoring Survey (see page 10) measures the changing prevalence of hepatitis C in current and former injecting drug users
(IDUs)6. In London, this survey estimated the prevalence of hepatitis in injecting drug users to be 59% in 2009, a level similar
to that seen five years before.

Number

Figure 2. Age-group and gender of individuals testing

positive for anti-HCV in sentinel laboratories in
London4 (2005 to 2009)

2000
1800
1600
1400
1200
1000
800
600
400
200
0

Fema l e

Table 1. Laboratory confirmed cases by risk exposure

in sentinel laboratories in London4 (2002 to 2006)

Risk exposure

Ma l e

1-14 15-24 25-34 35-44 45-54 55-64 65+Unknown

Age Group (yrs)

Percentage of
known cases

IDU

68.6%

Born/lived abroad

9.7%

Sexual - sex between men

8.4%

Blood transfusion

5.0%

Sexual - not stated

3.0%

Other

2.0%

Vertical infection

1.7%

Sexual - heterosexual

1.0%

Occupational

0.3%

Blood product

0.3%

Not completed

0.3%

Box 1: Hepatitis C in men who have sex with men (MSM) - Results from enhanced surveillance (SNAHC)5
HPA and collaborators established an enhanced surveillance system, The Enhanced Surveillance of Newly Acquired Hepatitis
C infection in men who have sex with men (SNAHC)5 in January 2008, collecting data prospectively from 22 centres in
London, Manchester and the South East.
Between January 2008 and March 2010, 218 newly acquired hepatitis C cases were reported, 84.4% of which were from
London centres. The median age at diagnosis was 38 years (range 19-62), the majority were UK born (63.3%) and of white
ethnic origin (90.8%). The majority of MSM (94.4%) had already been diagnosed with HIV. The main reason for these men
undertaking a HCV test, was as a result of raised liver function tests (LFTs). A history of intravenous drug use was reported for
21.1% (46/218) of cases, 30 of whom had injected within the previous six months.
Men reported a high number of sexual partners within the three months prior to their diagnosis. The majority had unprotected
insertive and receptive intercourse. The majority of men reported a sexual health screen in the last 12 months, two-thirds of
whom were diagnosed with one or more STI.
Three-quarters described the use of recreational drugs during the previous 12 months. The most commonly reported drugs
were cocaine (61.5%), ketamine (33.3%), ecstasy (31.3%) and methamphetamine (19.8%). Two-thirds of those who reported
drug use, reported having sex whilst under the influence of drugs, with a quarter of these men reporting this as occurring
often.
The findings provide evidence of ongoing sexual transmission of hepatitis C among HIV positive MSM, many of whom engage
in high risk sexual practices and frequently use recreational drugs during sex. This highlights the need for targeted public
health initiatives and continued enhanced hepatitis C surveillance in this group. Furthermore, these data emphasise the need
for hepatitis C assessment for all MSM with abnormal LFTs as well as routine screening for HIV positive MSM.
Other groups have also been shown to be at increased risk of infection, including individuals originating from South Asia where
the prevalence of hepatitis C is high, particularly those born in Pakistan7. Sentinel surveillance indicates that 2.9% of South
Asians tested at London sentinel laboratories between 2005 and 2009 were positive for hepatitis C (Figure 3). Although there
has been a slight increase in testing since 2006, fewer South Asians were tested in 2009 than in 2005.
As most new infections are acquired via injecting drug use, which often begins in late adolescence and early adulthood, the
number of positive tests in individuals aged 15 to 24 years can be used as a proxy indicator of incidence. There does appear
to be a downward trend in the number of 15 to 24 year olds testing positive in the sentinel laboratories in London from 82 in
2005 to 30 in 2009, although numbers are small4. This is in the context of a slight increase in tests in 20 to 24 year olds and a
slight decrease in testing in 15 to 19 year olds (Figure 4). The proportion of tests that are positive is decreasing in those aged
20 to 24 years old (from 2.1% in 2005 to 0.7% in 2009) and 15 to 19 years old (from 1.0% in 2005 to 0.5% in 2009).
It is important to estimate the number of people likely to need treatment to plan services effectively and we have to rely on
modelling for this. To support commissioners, the HPA has developed such a model and in London it is estimated that 51,203
people are infected with hepatitis C8 (Table 2). The estimated number of individuals with Hepatitis C varies from 2,965 in
Camden Primary Care Trust (PCT) to 941 in Barking and Dagenham PCT (Table 2).
Estimates of the future burden of disease and the costs of treatment, based on modelling by the HPA in 2007, are also shown
by PCT in Table 28. The estimated cost of treating those individuals already identified varies between almost 3.1 million in
Camden PCT to 1.0 million in Barking and Dagenham PCT and 54 million for London overall.

15-19 % pos i ti ve
15-19 tes ted

Number tes ted

4.0
3.0
2.0
1.0
0.0

Proportion positive

5,400
5,300
5,200
5,100
5,000
4,900
4,800
4,700

5.0

No. of young adults tested

Proportion positive

% pos i ti ve

Figure 4: Number of young adults tested and the

proportion testing positive for anti-HCV in sentinel
laboratories in London (2005 to 2009)4

2005 2006 2007 2008 2009

Year

20-24 % pos i ti ve
20-24 tes ted

2.5

4,000

2.0

3,000

1.5

2,000

1.0

1,000

0.5
0.0

2005 2006 2007 2008 2009

Year

No. of young adults

tested

Figure 3: Number of South Asians tested and the

proportion testing positive for anti-HCV in sentinel
laboratories in London (2005 to 2009)4

Table 2: Estimates of hepatitis C prevalence, burden, treatment and cost of treatment by PCT in
London8

Mild/
Moderate

Cirrhotic
or end
stage

Died

941

603

30

64

998,351

Estimated
annual
additional
no.
requiring
treatment
15

Barnet

1,478

947

46

100

1,568,779

23

219,629

Camden

2,965

1,900

93

201

3,147,170

47

440,604

City & Hackney Teaching

1,392

892

44

94

1,477,822

22

206,895

Enfield

1,702

1,091

54

115

1,806,787

27

252,950

Haringey Teaching

1,647

1,055

52

112

1,748,386

26

244,774

Havering

1,014

649

32

69

1,075,922

16

150,629

Islington

2,423

1,552

76

164

2,571,413

38

359,998

Newham

1,595

1,022

50

108

1,693,454

25

237,084

Redbridge

1,409

903

44

96

1,495,045

22

209,306

Tower Hamlets

1,813

1,162

57

123

1,924,323

29

269,405

Waltham Forest

1,139

730

36

77

1,209,259

18

169,296

Brent Teaching

1,650

1,057

52

112

1,751,733

26

245,243

Ealing

1,680

1,076

53

114

1,782,754

27

249,586

Hammersmith & Fulham

1,428

915

45

97

1,515,156

23

212,122

Harrow

1,021

654

32

69

1,084,115

16

151,776

Hillingdon

1,334

855

42

90

1,416,290

21

198,281

Hounslow

1,151

737

36

78

1,221,347

18

170,989

Kensington & Chelsea

1,515

971

48

103

1,608,250

24

225,155

Westminster

2,141

1,372

67

145

2,272,544

34

318,156

Bexley

1,010

647

32

68

1,071,742

16

150,044

Bromley

1,528

979

48

104

1,621,311

24

226,984

Greenwich Teaching

1,646

1,055

52

112

1,747,580

26

244,661

Lambeth

2,616

1,676

82

177

2,776,473

41

388,706

Lewisham

1,978

1,267

62

134

2,099,474

31

293,926

Southwark

2,559

1,639

80

174

2,715,636

41

380,189

Croydon

2,328

1,491

73

158

2,470,472

37

345,866

Kingston

888

569

28

60

942,101

14

131,894

Richmond & Twickenham

1,198

768

38

81

1,271,868

19

178,061

Sutton & Merton

2,285

1,464

72

155

2,424,986

36

339,498

Wandsworth

1,730

1,109

54

117

1,836,411

27

257,097

51,203

32,807

1,610

3,472

54,346,953

812

7,608,573

HPU

PCT

Barking and Dagenham

North
East &
Central
London

North
West
London

South
East
London

South
West
London

London

Estimated
total
infected
population

Estimated Burden in
2015
Estimated
cost of
treating
those already identified

Estimated
annual
cost of
treating
additional
cases

139,769

The total infected is based on estimates extrapolated from a national or regional level model estimate undertaken in 2003. The estimated
burden in 2015 is the predicted distribution of the above cases based on national level models of progression and incidence. It does not
allow for any additional incident cases, or for the impact of treatment (although the latter is expected to be very small).
The estimated cost of treating those already identified is based on costs estimated by NICE in 2006 and assuming that 50% of the
estimated 2003 infected population had been identified by 2006. The estimated cost of treating newly identified cases each year is based
on diagnosis rates of 7% of the estimated prevalence in 2003. This may include some people who have acquired infection since 2003, and
some that acquired infection some time ago but have newly presented for testing. It does not also allow for those already treated (which is
likely to be small) and is based on historical rates of drop-out.

2. Increasing awareness and reducing undiagnosed

infections
Hepatitis C infection is usually asymptomatic in the early years,
and therefore many individuals remain undiagnosed. The
Hepatitis C Action Plan2 identified that awareness-raising was
therefore an important component of reducing the burden of
undiagnosed infection.

Figure 5: Number of individuals tested and the

proportion testing positive for anti-HCV in sentinel
laboratories in London (2005 to 2009)4

Trends in testing are one indicator of increased awareness

and unfortunately there has been an apparent trend for a fall
in testing in London since 2005, although there was a slight
rise from 2008 to 20094. The data in Figure 5 from sentinel
surveillance show the numbers tested and proportions positive
in London4. The proportion testing positive for hepatitis C has
decreased from 5.0% in 2005 to 2.4% in 2009.

% pos i ti ve

Number tes ted

35,000

34,000

33,000

3
32,000

31,000

1
0

30,000
2005 2006 2007 2008 2009

Number of individuals
tested

Proportion positive

The awareness campaigns in England are now well

established. In 2009, the Department of Health launched new
campaigns targeting former IDUs (Get Tested, Get Treated)
and the UK population of South Asian origin (Hepatitis C. The
more you know, the better).

Year

Information from the sentinel surveillance indicates that testing was most often conducted by general practitioners (Figure 6)4.
However, this data does not include dried blood spot testing and oral fluid testing (commonly used in drug services). Trend
data suggests that testing by general practitioners has increased in the last five years, in contrast to testing in GUM services,
which has declined (Figure 7).
Testing in drug services (including dried blood spot testing and oral fluid testing) has increased slightly between 2005 and
2009 (Figure 8). The proportion testing positive for hepatitis C has declined from 40% in 2005 to 27% in 2009.

Figure 6: Number of individuals tested for anti-HCV and the proportion testing positive by service type in sentinel
laboratories in London (2005 to 2009)4

50000

35.0
32.5
30.0

35000

25.0

30000

20.0

25000
15.0

20000
11.4

15000

10.0

8.2
6.2

Primary services

Secondary services

1.3

Unknown

1.5

5.0
2.7
0.0

2.9
Unspecified ward^

Antenatal

Renal

Fertility services

Other ward type

Prison services

Accident and emergency

Drug dependency services

Occupational health

GUM clinics

2.0

0.4

General medical surgical

0.5

2.8
Obstetrics and gynaecology

3.1

Paediatric services

5.7

4.3

4.2

5000

Specialist liver services

10000

Unknown

% positivity

40000

General practitioner

Number tested

45000

Sentinel surveillance data indicates that of all positive tests,

over a third were detected in hospital (36.8%), just under
30% were detected in primary care and just under 20% in
GUM (Figure 9)4.

Hospital: Nonliver specialist

services
General
practitioner

16000
14000
12000

Number

The proportion of people tested that are positive varies

considerably with the source of testing (Figure 6)4. It is
particularly high in those testing in drug dependency services
(one in three people) and in prison services (one in nine
people). This compares to one in 25 people tested in general
practice and GUM, one in 16 tested in general medical and
surgery and one in 17 tested in A&E.

Figure 7: Number of Hepatitis C tests by service type in

sentinel laboratories by year in London (2005 to 2009)4

Occupational
health

10000
8000

GUM clinics

6000
Hospital:
Specialist liver
services
Accident and
emergency

4000
2000
0
2005 2006 2007 2008 2009

Drug dependency
services

Year

Prison services

Figure 8: Number of injecting drug users tested and

testing positive for anti-HCV in sentinel laboratories
in London (2005 to 2009)4
Number tes ted

10%

7%

5%

2%

er
Ot
h

A&
E

0%

Ge
n.

Year

8%
5%
2%

Ot
h

2005 2006 2007 2008 2009

13%

Re
na
l

16%

15%

er
wa
rd
se
m
r
Sp
v
ed
ice
ec
ica
s
ia l
ls
i st
ur
liv
ge
er
ry
se
rv
ice
s

10

19%

20%

ug

20

25%

Dr

30

28%

GU
M

40

30%

GP

1600
1400
1200
1000
800
600
400
200
0

Proportion of all positive tests

Proportion reactive

50

Number of individuals
tested

% reacti ve

Figure 9: Proportion of all hepatitis C positive

diagnoses by service type in sentinel laboratories in
London (2005 to 2009)4

3. Prevention and harm reduction

Prevention strategies primarily focus on injecting drug use, as
this is the most important risk factor for acquisition of the virus
in England today.

Figure 10: Hepatitis C test uptake amongst injecting

drug users and their awareness of their hepatitis C
infection in London (2000 to 2009)6

Reducing the number of individuals who begin injecting

drugs; encouraging injectors to quit injecting; reducing risky
behaviour (like sharing needles and syringes) in those who
continue to inject, and the early diagnosis and treatment of
those who become infected with hepatitis C are all
components of the prevention programme.

HCV Voluntary Confidenti al Tes t (VCT) Uptake

Proportion aware of HCV i nfection

100%
Percentage

80%

The delivery of successful prevention programmes in this

challenging risk group requires the integrated input of
government, professional organisations and public health and
healthcare professionals from a variety of clinical, social and
drug service backgrounds.

60%
40%
20%
0%

The HPAs Unlinked Anonymised Prevalence Monitoring

Survey monitors levels of risk and protective behaviours
among IDUs6.

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

It is encouraging to see that the proportion of IDUs taking up

the offer of a hepatitis C test has increased over the last 10 years and in 2009 reached 87% in London (Figure 10)6. However,
two thirds remain unaware of their infection (66.5%).
There is also a marked downward trend in the proportions of IDUs that report sharing equipment, with one in six reporting
direct sharing and one in three reporting both direct and indirect sharing in 2009 (Figure 11)6. Direct sharing is the sharing of
needles and syringes amongst those who inject in the previous four weeks. Indirect sharing is the sharing of mixing containers,
filters or the water used to prepared drugs.
One of the most obvious successes in harm reduction is the marked increase in hepatitis B vaccination uptake from 39% IDUs
in 2000 to 68% in 2009 (Figure 12)6.
Figure 11: Level of direct and indirect sharing
amongst injecting drug users in London (2000 to
2009)6

Figure 12: Uptake of hepatitis B vaccination amongst

injecting drug users in London (2000 to 2009)6

Level of s hari ng (di rect & i ndi rect)

Hepa ti tis B va cci ne upta ke

Level of di rect s ha ri ng

Percentage

Percentage

80%
60%
40%
20%
0%

80%
70%
60%
50%
40%
30%
20%
10%
0%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Year

4. Treatment of individuals with hepatitis C

Antiviral treatments are available that will successfully clear the virus in more than half of those treated (up to 80% success
rate if the genotype is favourable). Unless a major increase in those receiving effective treatment occurs, however, the future
burden of hepatitis C-related disease is likely to be substantial as indicated in Table 2. All national data sources (hospital
admissions from end-stage liver disease (ESLD); liver transplants and deaths) show that HCV-related liver disease is
continuing to increase year-on-year.
Only a small proportion of those tested for hepatitis C will typically receive treatment. This is often due to issues around referral
e.g. patients are not appropriately referred to a specialist, or do not attend appointments. In addition, treatment is not indicated
or appropriate in all patients. Co-ordination of high quality services for assessment and treatment was one of the key issues in
the Hepatitis C Action Plan.
Currently there are no national surveillance systems to monitor referral, uptake or response to treatment. In 2009/10, the HPA
undertook a pilot study to explore feasibility of estimating the number of individuals undergoing treatment for hepatitis C.
Amongst other things, the study collected data on: (i) the use of the drugs, Interferon and Ribavirin, by hospitals that treat
patients with hepatitis C, and (ii) information supplied via questionnaire by clinical centres on the numbers of individuals seen
and treated.
Based on the number of doses of drugs purchased in 2008, it is estimated that 1,478 patients were treated for hepatitis C in
London in 2008. Table 3 summarises the data that have been reported by clinical centres that treat patients with hepatitis C in
London in 2008. This data is far from complete, with just over a third of centres responding to the query from HPA Colindale.
The nine centres that responded reported starting treatment on 541 patients.
Table 3: Estimated numbers of patients treated in London based on information supplied by clinical centres on
the numbers of individuals seen and treated (HPA pilot study undertaken in 2009/10)
Number of hospitals/
centres treating
patients with hepatitis
C

Number of hospitals/
centres returning
questionnaire data

Number of new
patients seen

Number of patients
starting treatment in
2008

Number of patients
completing treatment in
2008*

28

649

541

481

* comprises patients starting treatment in 2007 and 2008

It is essential that robust treatment care pathways are in place in order for patients to be referred and treated appropriately. In
October 2010, the HPA conducted a survey of Health Protection Units (HPUs) which sought information on the proportion of
PCTs that had treatment care pathways in place, the proportion that had specific provision for prisoners and the proportion of
Drug Action Teams (DATs) that had joint prevention plans.
The extent to which HPUs were involved in the development of treatment care pathways or prevention plans in London is
summarised in Table 4. Only half of PCTs in London (17/33) were reported as having treatment care pathways. It was not
clear how many areas had care pathways with specific provision for prisoners.
Table 4: Results of a survey of HPUs in London regarding treatment care pathways in their area (HPA survey of
HPUs)
Proportion
of HPU involvement
in development or
review

No.
of
DATs

Proportion
of DATs
with joint
prevention
plans

Proportion
of HPU
involvement in
DAT Prevention
Plan

HPU

No. of
PCTs

Proportion
with treatment care
pathway

No. of
prisons

Proportion of
care pathways
with specific
provision for
prisoners

North East
& Central
London

12

33%

Less than half

More than
half

13

Less than
half

More than
half

North West
London

38%

Not known

Less than
half

Not known

None

South East
London

100%

More than half

All

Not known

None

South West
London

80%

Not known

More than
half

Not known

Not known

5. References
1. Hepatitis C in the UK 2009. London: Health Protection Agency Centre for Infections, December 2009. Available at:
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1259152221168
2. Department of Health. Hepatitis C Action Plan for England 2004. London, Department of Health. Available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4084713.pdf
3. Health Protection Agency. Hepatitis C diagnosis increasing but awareness-raising and rates of testing need to be sustained.
Health Protection Report 4 (19): news. Available at: http://www.hpa.org.uk/hpr/archives/2010/news1910.htm#hcv
4. Sentinel Surveillance of Hepatitis Testing. Available at: http://www.hpa-bioinformatics.org.uk/hepc/home.php
5. The Enhanced Surveillance of Newly Acquired Hepatitis C infection in men who have sex with men (SNAHC). Available at:
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIVAndSTIs/SurveillanceSystemsHIVAndSTIs/hivsti_SNAHC/
6. Unlinked Anonymous Survey of Injecting Drug Users. Available at:
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/12021155191836.
7. Uddin G et al. Prevalence of chronic viral hepatitis in people of south Asian ethnicity living in England: the prevalence
cannot necessarily be predicted from the prevalence in the country of origin. Journal of Viral Hepatitis 2010; 17(5): 327-335.
8. HPA Commissioning Template for Estimating HCV Prevalence by PCT and Numbers Eligible for Treatment. Available at:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947397614

6. More information about specific data sources

Sentinel Surveillance of Hepatitis Testing Study: This was set up in 2002 to enhance routine surveillance of hepatitis C.
The study collects data on laboratory test results and demographic data for all individuals tested for hepatitis C antibody in 24
sentinel laboratories in England, covering approximately one third of the population. There are nine participating centres in
London; HPA Colindale, North Middlesex Hospital, St Barts and the London Hospital, Kings College Hospital, St Georges
Hospital, Chelsea and Westminster Hospital, Ealing Hospital, Northwick Park Hospital and University College Hospital.
Limitations of the data include some duplication of individual patients and exclusion of dried blood spot, oral fluid, reference
testing, and testing from hospitals referring all samples which do not have the original location identified. Individuals aged less
than one year, in whom positive tests may reflect the presence of passively-acquired maternal antibody rather than true
infection, are excluded.
Unlinked Anonymised Prevalence Monitoring Survey: This survey measures the changing prevalence of hepatitis C in
current and former injecting drug users (IDUs) who are in contact with 60 specialist drug agencies (e.g. needle exchange
services and treatment centres) in England, Wales and Northern Ireland.6 The programme also monitors levels of risk and
protective behaviours among IDUs.

7. Acknowledgments
For further information contact paul.crook@hpa.org.uk
This report was compiled by:
Sandra Johnson
Epidemiology scientist, HPA South East Regional Epidemiological Unit
Paul Crook
Consultant Medical Epidemiologist, HPA London Regional Epidemiological Unit
Grainne Nixon
Nurse Consultant, HPA London Hepatitis Lead, NECLHPU
The report was reliant on the following:
Health Protection Agency Colindale
Sarah Collins, Lisa Brant and Dr Sam Lattimore (Sentinel Surveillance of Hepatitis Testing & oral fluid testing data provided by
Concanteno Plc) - http://www.hpa-bioinformatics.org.uk/hepc/home.php
Dr Vivian Hope (Data from Unlinked Anonymous Monitoring Survey of HIV and Hepatitis in Injecting Drug Users)
Dr Helen Harris & Dr Brenda Thomas (Results of a pilot study to explore feasibility of estimating the numbers of individuals
undergoing treatment for hepatitis C)
Dr Mary Ramsay (Commissioning Template for Estimating HCV Prevalence by PCT and Numbers Eligible for Treatment; general comments and help with co-ordination of data for the template)

Health Protection Agency North West

Kathy Chandler & Dr Catherine Quigley (compiled the regional template report & collated each regions data)

10